Shaheen Akbar Agha  ( Department of Community Medicine, Sindh Medical College, Karachi. )

Objective: To identify neglected aspects of primary health care activities and propose effective strategies for better health promotion in Pakistan.
Method: An observation study was carried out from March-July, 1998 in a low-medium income group in Karachi West in a primary health care set-up.
Results: Seventy-three percent of female clients were influenced by the advice of male members of the family, 22% followed the directions of elderly female member, 5% availed health services on their own will.
Conclusion: The Pakistani female community is influenced strongly by the male members of the family in almost all health related activities OPMA 49:309,1999).

Pakistan is a developing country, with an estimated population of 130.58 million (1998 census)¹ giving an image of a typical ‘Christmas Tree’ population pyramid. It has a high Infant mortality rate (IMR) of 95/1,000, maternal mortality of 25,000-30,000/ year and a low literacy rate and fertility rate of 6.0². In spite of its economical crisis and constraints, Health Care Managers are striving to spell out the issues which can combat with the failures and hurdles in health promotion - Gender issue being one of them.
Pakistan is a Muslim country with strong perceptions, values and beliefs for religion and culture. With a male dominant society with approximately 68% of population living in rural areas; the dilemma for health consultants is to promote health-care activities in the domain of social and cultural norms.
In this scenario, the ‘trickle down’ programs from the developed nations are not meeting the needs of the country.
The analysis of work and experience in community based health programs for the last 10 years and research study in the-up-take behavior of health promotion activities e.g., family planning, immunization, ante-natal care, nutrition and diarrhea control programs have indicated a strong need for highlighting the gender issue in health promotion activities in Pakistan. The male member being the key decision maker in all priority issues of the family needs to be focused in the agenda for all health related services.
An observational study was done to determine the effect of influence of male members of the family, unconditional to whatever relation they had with the female client (in the form of husband, father-in-law or brothers) on the uptake pattern of utilizing the health care services provided by the public and private sector.

One hundred female clients were interviewed. Fifty were taken from the out-patient section of primary health care center with a selection of 10 clients on alternate days making a set of 5 sessions, whereas SO were selected from the catchment area of the same health center in the form of snowball sampling.


The study revealed that 73% of the female clients are influenced by the advice or permission of the male members of the family to practice the health promotion services, which includes attending a health center, a health education session or uptake of health services at the door step.
Twenty-two percent of the clients were under the influence of the elderly female members of the family e.g., grand mother, mother or mother-in-law etc. for the above quoted activities. Only 5% of the females were utilizing healthcare services according to their needs in addition attending health education programs and involved in social welfare programs on their own will.

Pakistan is a signatory to a number of projects relating to the most vulnerable group - the mother and child which reflects the health status of any country. Some of these are:
Social Action Program (SAP) in collaboration with World Bank which aims at strengthening the health services including the referral backup system from rural to urban health centers for maternal and child health care.
Safe Motherhood Initiative (SMI) along with 126 other countries, Pakistan moves towards reducing the maternal mortality by 50% by the year 2000.
Trained Birth Attendant (TBA) Training Program to deal with 70-80% of the home deliveries in rural areas.
Family Planning Prograni targets to reduce the Growth Rate from 3.1% to 2.6% by the year 2000.
The National Expanded Program of Immunization (EPI) aims at immunizing mother from tetanus and children from six killer diseases common in Pakistan e.g., tuberculosis, tetanus, measles, diphtheria, pertussis and polio.
In addition, numerous other governmental and non­governmental organizations are struggling for health promotion and for a better health status in the country.
Yet there is a missing link in the chain at some stage; where health communication needs to play a role and the gender issue should emerge as a nidus for action in all health promotion programs.
The prevention of disease and the promotion of health lie not only in the hands of medical profession and doctors but also in the lifestyle and social condition in which people live in³ (Table).
Health Education must also be directed towards groups who can directly influence those with health problems. These are the ‘gatekeepers’ and social reinforces (e.g., parents, husbands, brothers, father-in-laws, teachers and opinion leaders). It is thus logical to address the health related activities to the male members of the society to bring about a change in the knowledge, attitude and practice in the entire population. As this study reveals 73% of female client health care was influenced by the advice of male members of the family. It was also observed that parents deal with 90% of childhood diseases themselves and parents participation in the use of preventive services such as a child health clinic can improve both their effectiveness and efficiency⁴.
The availability of equal opportunity to both genders to grow physically, emotionally and intellectually can enhance the process of health to the family, community and the nation.
The male influence in health care programs has stimulated new insight for development in health promotion programs this can be achieved by targetting male members of the community by messages through trade unions in local factories/organizations and work places and can be communicated through leaflets, posters, pamphlets attached to pay slips etc. Mosques and religious leaders should be involved, mobile teams for health education to be set upon Friday - the Prayer day. Clubs and places most frequently visited by males like cinema houses, play grounds or by organizing Fathers day at school and health centers.
Researchers and health service management consultants are trying to pave in the gap between policies and procedures. What will be practiced depends upon the health care providers and communities as to how they fulfill their own potential, overcome their dilemmas and live life in a healthy way.

1. Report on population census, 1998, Federal Bureane of Statistics, Islamabad.
2. The State of World Children, 1996, 50th Anniversaty issue UNICEF, Oxford University Press.
3. Dr. John Hubly, Communicating Health. Macmillan Press, London, UK, 1993, Chapter I, Page No. 6.
4. Graham H. Caring for the family research Report-I-London Health Education Council, 1988.